Solid organ transplant recipients have an elevated risk of tuberculosis (TB) with high mortality. Data about TB in this population in the United States is sparse. We present four cases of active tuberculosis in kidney transplant recipients at our center. All patients had possible TB exposure prior to transplant and all were diagnosed with active TB within the first year of transplant. Disseminated TB was seen in half of the patients with extra-pulmonary TB being more common affecting lymph nodes, pericardium, and the kidney allograft. Delay in diagnosis from onset of symptoms ranged from fifteen days to two months. Two patients died from TB. TB is a largely preventable and curable disease. However, challenges remain in the diagnosis due to most recipients presenting with atypical symptoms. Physicians should maintain a high degree of suspicion for TB to promptly diagnose and treat post-transplant thereby minimizing complications. A review of the literature including the epidemiology, pathogenesis, clinical presentation, diagnosis and treatment options are discussed.

Tuberculosis is a healthcare concern that affects millions of individuals around the globe. Coinfection with HIV has changed both the clinical presentation and the outcome of the disease dramatically in the last few decades. Extrapulmonary tuberculosis is seen more frequently in the immunocompromised host. An unusual case of gastric tuberculosis in an AIDS patient is reported here. A 49-year-old female with AIDS was admitted for fever and epigastric pain. A gastric submucosal abscess was observed on imaging and confirmed by biopsy showing numerous neutrophils and acid-fast bacilli. Aspirate grew Mycobacterium tuberculosis. This report highlights a very unusual presentation of tuberculosis in an immunodeficient patient. High clinical suspicion for opportunistic infections in unusual locations should be maintained in these patients presenting with clinical syndromes that do not respond to standard treatments. New diagnostic modalities facilitate accurate identification of these infections.

PRESENTATIONA 64-year-old woman presented with erythematous nodules on the left hand, forearm, and upper arm developing over 2 months. A single nodule was first noted on the dorsum of the left hand, followed by progressive development of several similar nodules on the left forearm and upper arm. She also reported a small cut on the left fifth digit with persistent pain, redness, and drainage of clear fluid for several months. Over the course of her illness, the patient had been treated with amoxicillin/clavulanate and then cephalexin but did not notice any improvement. She denied any medical problems, toxic habits, recent trauma to the hand, or exposure to marine water. She was a native of China and had been living in New York City for 29 years with no recent international or domestic travel. She reported gardening at home on a regular basis and said she had been applying plant leaves and thorns to the area of injury on her hand as part of a traditional Chinese remedy. Review of systems was negative for fever, night sweats, weight loss, or joint swelling. ASSESSMENTOn physical examination, the patient's temperature was 37 C, blood pressure was 168/84 mm Hg, and pulse was 80 beats/min. Multiple subcutaneous erythematous nodular lesions were noted on the left upper extremity extending proximally in a linear fashion from the dorsum of the left hand to the forearm and upper arm ( Figure A). A small cut was observed on the palmar aspect of the left fifth digit with mild surrounding erythema, swelling, and minimal drainage of clear fluid. There was no epitrochlear or axillary lymphadenopathy, and the remainder of the physical examination results were normal. The patient had a total white blood cell count of 8800/mL with a normal differential count. Hepatic and renal function were normal. DIAGNOSISThe patient was administered empiric itraconazole for Sporothrix schenckii infection (sporotrichosis) acquired during gardening. Two weeks into the course of therapy, the patient's skin lesions were unchanged with the exception of a few small nodules on the forearm that showed mild interval decrease in size. Biopsy of a nodule was performed. Histopathology showed dense inflammatory infiltrate in the dermis with numerous neutrophils and focal necrosis with surrounding histiocytes, lymphocytes, and plasma cells. Numerous acid-fast positive bacilli were seen on both acidfast and Fite stains. Grocott's methenamine silver stain and periodic acid-Schiff stains were negative for fungi. Culture of the biopsy tissue grew Mycobacterium marinum. On further questioning, the patient recalled antecedent trauma to the left hand from a fish scale while cooking.Our patient's case highlights a common diagnostic dilemma. There are no pathognomonic clinical features of Mycobacterium marinum infection, and delay in diagnosis is common. 1 Most patients present with papules or nodules of the upper extremity. Less commonly, abscess and ulcer formation are seen. 2 Lymphocutaneous spread similar to sporotrichosis, nocardia, and other nontuberculous myc...

No abstract